Brain Abscess and Stroke in Children and Adults With Hereditary Hemorrhagic Telangiectasia: Analysis of a Large National Claims Database

OBJECTIVE

Hereditary hemorrhagic telangiectasia (HHT) is an inherited disease associated with pathogenic variants in TGF-β signaling pathway-related genes, resulting in abnormal vascular development in various organs. Brain arteriovenous malformations (AVMs) may lead to intracranial hemorrhage, and brain abscess or ischemic stroke may result from right to left shunting via pulmonary AVMs. We aimed to investigate the risk for these severe complications in both adult and children HHT patients.

METHODS

We conducted a case-control study among participants aged 1-64 years in the MarketScan® Commercial (2006-2019) and Multistate Medicaid Databases(2011-2019). We identified cases with HHT using International Classification of Diseases diagnosis codes (ICD-9-CM 448.0, ICD-10-CM I78.0). Control patients without HHT coding were frequency matched 10:1 to HHT patients by age, duration of insurance enrollment, sex, and Medicaid status. Outcomes of interest (brain abscess, stroke and intracranial/subarachnoid hemorrhage) were identified using the appropriate ICD-9/10 diagnosis codes. We calculated incidence and standardized rates of the various outcomes and compared rate ratios (RR) between HHT cases and controls.

RESULTS

5796 patients with HHT, of which 588 were children (age <16 years) were matched with 57,960 controls. There was increased incidence of brain abscesses in HHT cases compared with controls, with an RR of 35.6 (95% CI 15.4 - 82.5). No brain abscesses were recorded in children aged 15 years or less. Hemorrhagic strokes/subarachnoid hemorrhages were more common in HHT cases, with an RR of 4.01 (95% CI 2.8 to 5.7) in adults and 60.2 (95% CI 7.2 - 500.4) in children. Ischemic strokes were also more common in cases, with an RR of 3.7 (95% CI 3.0 - 4.5) in adults and 70.4 (95% CI 8.7- 572.3) in children.

CONCLUSION

We observed much higher incidence of severe CNS vascular complications in HHT patients, particularly in children. Though higher incidence of brain abscesses was noted in adult HHT patients, no brain abscesses were recorded in children, a result that may be considered when surveillance recommendations for this population are revisited.

Postdischarge prophylactic antibiotics following mastectomy with and without breast reconstruction

BACKGROUND

Prophylactic antibiotics are commonly prescribed at discharge for mastectomy, despite guidelines recommending against this practice. We investigated factors associated with postdischarge prophylactic antibiotic use after mastectomy with and without immediate reconstruction and the impact on surgical-site infection (SSI).

STUDY DESIGN

We studied a cohort of women aged 18-64 years undergoing mastectomy between January 1, 2010, and June 30, 2015, using the MarketScan commercial database. Patients with nonsurgical perioperative infections were excluded. Postdischarge oral antibiotics were identified from outpatient drug claims. SSI was defined using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis codes. Generalized linear models were used to determine factors associated with postdischarge prophylactic antibiotic use and SSI.

RESULTS

The cohort included 38,793 procedures; 24,818 (64%) with immediate reconstruction. Prophylactic antibiotics were prescribed after discharge after 2,688 mastectomy-only procedures (19.2%) and 17,807 mastectomies with immediate reconstruction (71.8%). The 90-day incidence of SSI was 3.5% after mastectomy only and 8.8% after mastectomy with immediate reconstruction. Antibiotics with anti-methicillin-sensitive Staphylococcus aureus (MSSA) activity were associated with decreased SSI risk after mastectomy only (adjusted relative risk [aRR], 0.74; 95% confidence interval [CI], 0.55-0.99) and mastectomy with immediate reconstruction (aRR, 0.80; 95% CI, 0.73-0.88), respectively. The numbers needed to treat to prevent 1 additional SSI were 107 and 48, respectively.

CONCLUSIONS

Postdischarge prophylactic antibiotics were common after mastectomy. Anti-MSSA antibiotics were associated with decreased risk of SSI for patients who had mastectomy only and those who had mastectomy with immediate reconstruction. The high numbers needed to treat suggest that potential benefits of postdischarge antibiotics should be weighed against potential harms associated with antibiotic overuse.